Regional Advocacy Tool

Transcription

1 Regional Advocacy Tool Sexual and Reproductive Health and Rights Advocacy in the Caribbean Tonya Haynes, PhD Cherise Adjodha

2 Copyright : Development Alternatives with Women for a New Era (DAWN) This paper may be used freely but with clear referencing to the author and DAWN. It may be referenced as follows: Tonya Haynes, Cherise Adjodha DAWN Regional Advocacy Tools: Sexual and Reproductive Health and Rights Advocacy in the Caribbean. DAWN. Suva (Fiji). 1

3 Table of Contents List of Tables... 3 List of acronyms... 4 I. Executive Summary... 5 Introduction - Understanding the Caribbean Context... 6 Regional Overview... 7 II. THEME 1: Comprehensive Sexual and Reproductive Health Services HIV/AIDS Overview Maternal Health and Family Planning SRHR Advocacy in the Region Snapshot: SRHR in Caribbean Media Recommendations III. THEME 2: Sexual and Reproductive Health Rights of Young People Barriers to Comprehensive Sexuality Education Child Sexual Abuse Legal Barriers for Youth Access to SRHR and Services Mapping SRH Services & Activism in Belize IV. THEME 3: Sexual and Reproductive Rights Sex and Crime Policing Sexuality Same sex Relations Sex Work Addressing Spousal Rape Abortion Transforming legal systems and frameworks V. Conclusion

4 List of Tables Table 1: Sexual & Reproductive Health Indicators for Women 8 Table 2: Overview of Caribbean SRHR Issues & Context 9 Table 3: HIV Prevalence 13 Table 4: Maternal Mortality at a Glance (most recent data) 14 Table 5: Trends in estimates of maternal mortality ratio 15 Table 6: Access to Contraceptive Services 16 Table 7: Criminalisation of same sex activity in the Caribbean 24 Table 8: Status of Caribbean Abortion Laws 29 3

5 List of acronyms AIDS BFLA BFPA FSW GSHS HIV HFLE ICPD IPPF MDGs MMR MSM NGO PANCAP PLHIV POWA SRH SRHR UNAIDS WB W HO YAM Acquired Immune Deficiency Syndrome Belize Family Life Association Barbados Family Planning Association Female Sex Workers Global School Health Survey Human Immunodeficiency Virus Health and Family Life Education International Conference on Population and Development International Planned Parenthood Federation Millennium Development Goals Maternal Mortality Ration Men who have Sex with Men Non-Government Organisation Pan Caribbean Partnership Against HIV & AIDS Persons Living with HIV Productive Organisation for Women in Action Sexual and Reproductive Health Sexual and Reproductive Health Rights United Nations Joint Programme of HIV and AIDS World Bank World Health Organisation Youth Advocacy Movement 4

6 I. Executive Summary The ICPD Programme of Action (PoA) specified a range of SRH services that countries should strive to provide to make progress towards delivering integrated and comprehensive SRH services. Inter-alia this included contraception, maternity care, access to safe abortion, and the prevention and treatment of sexually transmitted infections including HIV, and reproductive health conditions. While Caribbean countries are guided to a large extent by the WHO in ensuring that the right to health is fulfilled, sexual and reproductive health and rights (SRHR) are typically interpreted in the context of reproductive functions, and therefore are not comprehensively addressed. The political commitment required for a sexually healthy society in the Caribbean is for governments to recognise sexual health as a fundamental human right and promote it as such. Social institutions, including governmental agencies, need to develop and implement public policies involving clear and precise directions for protecting and promoting sexual health as a fundamental human right. Legislation is necessary that protects the vulnerable from exploitation (e.g., child prostitution), recognizes the rights of all persons to integrity of the body, protects the rights of sexual minorities to such fundamental human rights as education, health, and employment (e.g. anti-discrimination legislation), and promotes equity across sexual dimensions (e.g. equal opportunity legislation). Universal access to age-appropriate, comprehensive sexuality education across the lifespan needs to be introduced to many Caribbean countries. And to ensure persons have access to services, an infrastructure of professionals and paraprofessionals specializing in sexual concerns and problems is necessary. This includes the provision of training programs for professionals to specialize in Sexual Health. The limiting factors to achieving these goals in the Caribbean are often economic, many countries are small and have few resources to allocate to SRHR services, funding provided by other agencies has been delivered to specific services, such as HIV prevention, when an integrated approach to sexual health is the preferred option. Governments can show they are serious about becoming a sexually healthy society in the areas of education and legislation, by standing against the outdated attitudes of religious leaders who seek to oppose progress based on their own opinions and interpretation of the guidelines put forward by the ICPD PoA. There is much room for improvement on SRH issues across the Caribbean, progressive legislation on abortion and clear direction on the rights of young and marginalised people to fight child sexual abuse could be the first steps in providing the leadership the region requires to recognise the importance and positive effects that sexual health can have on society in general. 5

7 Introduction - Understanding the Caribbean Context The ICPD Programme of Action (PoA) specified a range of SRH services that countries should strive to provide to make progress towards delivering integrated and comprehensive SRH services. Inter-alia this included contraception, maternity care, access to safe abortion, and the prevention and treatment of sexually transmitted infections including HIV, and reproductive health conditions. 1 In the Caribbean, the focus on HIV and AIDS prevention and treatment has provided some impetus for expanded sexual health service provision. However, HIV and AIDS health service provision is not integrated into a comprehensive sexual and reproductive health approach. This is largely a result of a more centralized approach to HIV and AIDS prevention, treatment, care and support, which has been favoured by development and donor agencies. For example, the United Nations Joint Programme of HIV and AIDS (UNAIDS) put forward a framework referred to as the Three Ones, which was officially supported as the preferred framework for addressing the HIV and AIDS epidemic in the Caribbean, by other UN agencies including the WHO, donor governments and the World Bank (WB). The Three Ones main goal was to facilitate a coordinated HIV and AIDS response through the establishment of one national HIV and AIDS framework, one national coordinating agency and one monitoring and evaluation system. The approach depends upon a multi-sectoral response to HIV inclusive of the private sector 2. Such an HIV centred vertical framework has prevented a more inclusive, integrative approach towards SRH service provision. This advocacy tool seeks to collate and make accessible relevant data and information on key issues of sexual and reproductive health and rights (SRHR) in the Caribbean with particular emphasis on the English-speaking Caribbean and Haiti (though data from Cuba, Puerto Rico and the Dominican Republic is also presented). It also seeks to provide analysis of the key SRHR issues in the region toward strategies for intervention. The chief mode of inquiry is a review and critical analysis of issues arising from governmental and international agency reports on diverse areas such as HIV/AIDS, maternal health, child health, sexual and other forms of gender-based violence and adolescent sexuality among others. This review and analysis is supplemented with a review of academic literature on the subject as well as consultations with activists in the field, particularly young activists who form part of the CatchAFyah Caribbean Feminist Network. In reviewing this material, it is important to remember that this is not meant to be a comprehensive account. Rather, the purpose is to identify current trends and the corresponding challenges undermining access to SRHR. Sexual and reproductive health and rights encompass a wide range of issues, services, 1 United Nations Report of the International Conference on Population and Development, Cairo, September 5 13, Paragraph 7.6. Accessed 21 July 2013 at: 2 UNAIDS. Retrieved online on 21 July 2013 at: 6

8 areas of law and cross-cut many other issues such as economic empowerment and gender justice. The regional advocacy tool is limited to the following four areas of consideration: 1. Youth (focus on access to services and comprehensive sexuality education as well as child sexual abuse) 2. Services (focus on legality and accessibility of safe abortion) 3. Rights (focus on criminalisation of sexual behaviour) As far as possible data is presented for as many Caribbean countries as there is data available. However, there are large gaps in data for many countries so examples from a particular country may sometimes be used to better illuminate a particular issue. Countries for which there is no data available highlight the need for support for data collection and the availability of timely and accessible data. Our overriding objective is to map the gaps in services and accessibility, and offer ideas for strategic advocacy points and areas of focus. According to the current working definition by the World Health Organisation (WHO), sexual health is: a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled (WHO, 2006a 3 ). While Caribbean countries are guided to a large extent by the WHO in ensuring that the right to health is fulfilled, sexual and reproductive health and rights (SRHR) are typically interpreted in the context of reproductive functions, and therefore are not comprehensively addressed. The primary reason for this is the dominant thinking that normal sexual relations are meant to be heterosexual, with a view towards procreation, thereby denying inclusion of Lesbian, Gay, Bisexual, Transgender, Queer, Intersex (LGBTQI) services as well as any acknowledgement of the needs of sex workers. Regional Overview Table 1 below shows the basic SRHR indicators published in 2011, the Dominican Republic and Jamaica have the highest MMRs in the region, though in Table 6 the data shows Haiti had much higher MMRs in 2015, and these three countries are joined by the Bahamas for the highest levels of HIV infections. This table also highlights a number of countries have no statistical data on a number of SRH indicators for certain time periods, and this absence of reliable information prohibits their ability to develop and subsequently monitor and evaluate SRH policies and programs. It also prohibits holding a government 3 Sourced online at: 7

9 Country accountable for the availability, access and quality of SRH services. Table 1: Sexual & Reproductive Health Indicators for Women % births to women ages Maternal Mortality ratio (per 100,000 live births) last available yr 8 Corrected death rates (per 100,000 women) due to malignant neoplasms of cervix, last 3 year period available Women (%) among those aged 15 or older who are infected with HIV 2009 Antigua & Barbuda Data not available Data not available 9.8 Data not available Aruba 5.0 Magnitude zero 5.5 Data not available Bahamas 2.7 Data not available Barbados 4.1 Data not available 7.9 <0.5 Belize 7.7 Data not available Cuba Dominica Data not available Data not available 12.0 Data not available Dominican Data not available or 59 Republic applicable French Guiana 7.1 Data not available 3.0 Data not available Grenada 3.4 Magnitude zero 12.9 Data not available Guyana 5.6 Data not available Haiti 4.2 Data not available Data not available or 61 applicable Jamaica Montserrat Data not available Magnitude zero Magnitude zero Data not available St. Kitts Nevis Data not available Data not available 5.5 Data not available St. Lucia 4.5 Data not available 13.6 Data not available St. Vincent 4.0 Data not available 11.1 Data not available Suriname 3.5 Data not available Trinidad & Tobago 3.2 Data not available Source: Gender, Health and Development: Basic Indicators 2011 published by PAHO, UNFPA, UN WOMEN, UNECLAC Table 2 provides an overview of the status of a number of SRHR issues in the Caribbean. Many SRHR indicators show there is still much work to be done, HIV is a leading cause

10 of death, access to contraceptives is also limited, and the legality of supply is inconsistent and confusing. Abortion is still illegal in many countries, and even where it is legal it is not accessible. Disparity between church and state in the Caribbean is the cause of much confusion at the grass roots level, the law and government initiatives conflict with the stance of religious leaders, and the personal beliefs of practitioners, for many SRHR issues. Table 2: Overview of Caribbean SRHR Issues & Context Issue HIV HIV among youth Feminisation HIV Sexual Violence Contraceptive Use/Family Planning of Access to safe and legal abortion Migration Maternal Mortality Context High prevalence, leading cause of death among women and men aged In many countries prevalence among young women is double that of young men. While men s prevalence rates outstripped women in the early days of the epidemic and continue to do so in many Caribbean countries, women now make up 48% of PLHIV in the region. Jamaica, Bahamas, St. Vincent and the Grenadines have among the highest rates of reported rape in the world according to Crime Trends Survey cited by UN WOMEN. Significant unmet need for contraception in some countries linked to religious and cultural attitudes and gender inequality. Access to a variety of modern methods at low cost in some countries like Barbados. Youth access remains an issue due to illegality/confusion about the law and/or requirement of parental permission. Barbados and Guyana have the most permissive laws but despite legality, abortion is inaccessible in Guyana as the main public hospital does not offer the service. Most Caribbean countries permit abortion in very limited circumstances such as to save the mother s life. The Dominican Republic does not even permit abortion in this circumstance. Migrant status is a key predictor of poverty and social exclusion in the Caribbean. Many migrants face difficulties accessing healthcare services some of which are due to overt discrimination against the undocumented. Haiti has a high MMR, Guyana has the second highest in the region. Maternal mortality must be understood as linked to the socioeconomic context as well as the strength of the health care system, women s economic empowerment, accessibility of contraception and safe abortion. 9

11 Issue Comprehensive sexuality education Integration of SRH services Women in decisionmaking Child sexual abuse Gender Equality Sexual Rights Youth Unemployment Context Inability to reach young people out of school; comprehensive curriculum developed but is unevenly used. Jamaica s Minister of Education recently announced a new Health and Family Life Education (HFLE) curriculum that would exclude homosexuality and condoms. In Belize, the education system is a church-state partnership that has hindered the provision of adequate SRH education and services to the young and even to the rest of the public. In Antigua and Barbuda, Christian Family Life Education is offered in schools. Services not integrated. HIV treatment separated from other health services. Maternal and child health focus of women s health services. There have been news reports of doctors in Tobago refusing to treat sexual assault victims in order to avoid the hassles of a lengthy, timeconsuming court process. Highest levels of decision-making are male-dominated. Young women have comparatively higher levels of education but young women s participation in decision-making still limited. 48% of adolescent girls report sexual initiation to be forced or somewhat forced in 9 Caribbean countries. 4 Child sexual abuse is linked to lower use of condoms. 5 Physical or sexual abuse is linked to sex by age Pervasive feeling expressed by politicians, some academics, in media and by men s rights groups that Caribbean governments have focused on women to the neglect of men and men are now marginalized and losing ground to women. Has created difficulties in advocating for gender equality from a feminist perspective. Most Caribbean countries criminalise both men s and women s samesex practices. Guyana has laws against cross-dressing used to criminalise and harass trans women. Vagrancy laws similarly used in Trinidad and Tobago. Laws against buggery are often used to prosecute in cases of sexual abuse of boys. This is often given as the reason for retaining laws that criminalise anal sex. Youth unemployment rates are higher than those for the general population. 4 WOMEN, UN, "Advocacy Brief: Ending Violence against Women" (accessed August ). 5 Allen, Caroline F., and Yasmin Solitahe Odlum, "Violence against Women and Hiv in the Caribbean: An exploration of Linkages and Interventions", Organisation of American States ages_and_interventions (accessed August ). 6 Ibid 10

12 Issue Media Violence Against Women STI prevention Marital Rape Sex Work Context Recent work on 11 Caribbean countries by Women s Media Watch of Jamaica indicated that: male government officials were the major newsmakers; just over 80 per cent of voices were male spokespersons and nearly 70 per cent were male experts; men were represented three times more than women in 65 newspapers and newscasts; the majority of women in the news were politicians and then professionals in health and education, while female sources were more likely chosen by female reporters; less than 10 per cent of stories (written by men) challenged gender stereotypes. Media monitoring by CODE RED for gender justice has revealed derogatory representations of homosexual men, pervasive backlash against women and women s issues, frequent reports of violence against women. HIV prevention and avoidance in the context of heterosexual partnerships is the dominant SRHR messaging on Caribbean media. Caribbean feminists are creating their own media but this has very limited reach. Data from the Caribbean suggests 30% of women experience violence. 7 Country studies for Antigua and Barbuda, Guyana, British Virgin Islands and Suriname suggest that between 20-69% of women in intimate relationships have been victims of domestic violence. 8 Located within HIV prevention despite cultural attitudes which see condom use as inappropriate for serious, long-term relationships and marriage. Legal/parental consent barriers to youth access to STI testing. Illegal in Grenada and Trinidad & Tobago but in Grenada carries a shorter sentence than non-marital rape. Illegal in Barbados only if there is a legal separation or decree nisi of divorce. Bahamas government to consider marital rape bill. Largely criminalized and stigmatized. Some of it is linked to tourism and involves minors. Sex worker organisations exist in Guyana and Suriname. 7 Allen, Caroline F., and Yasmin Solitahe Odlum, "Violence against Women and Hiv in the Caribbean: Anexploration of Linkages and Interventions", Organisation of American States ages_and_interventions (accessed August ). 8 WOMEN, UN, "Advocacy Brief: Ending Violence against Women" (accessed August ). 11

13 II. THEME 1: Comprehensive Sexual and Reproductive Health Services This section will highlight some of the existing challenges/barriers to adequate and respectful care in the provision of SRH services. It will provide an overview of HIV/AIDS and Maternal health and family planning, areas for which there has been a considerable focus of funding and programs in the region. HIV/AIDS Overview The Caribbean is second only to sub-saharan Africa in terms of HIV prevalence, and HIV is the leading cause of death of women and men ages UNAIDS has identified sex workers and men who have sex with men (MSM) as two vulnerable groups. Among female sex workers (FSW) HIV prevalence is high compared to the prevalence in the adult population. Data from indicate that there is considerable regional variation in HIV prevalence amongst FSW, ranging from 2.7% in the Dominican Republic to 27% in Guyana. This population plays an important role in the spread and acquisition of HIV, e.g. in Jamaica, 25% of reported AIDS cases indicated unprotected sex with FSW as the mode of acquisition of the HIV infection. The HIV prevalence among MSM varied from 6.1% in the Dominican Republic to 32% in Jamaica. Nonetheless laws in many Caribbean countries continue to criminalise sex work and same-sex sexuality practices fuelling stigma, discrimination and homophobia. In addition, laws which criminalise cross-dressing also support a culture of exclusion of trans women. Data from the Caribbean suggest that while MSM are a group with a high HIV prevalence, some Caribbean countries have seen a feminization of HIV. Data from 2009 indicate that, in the Bahamas (61%), Belize (59%), Dominican Republic (59%), Guyana (51%) and Haiti (61%), women make up the majority of those ages 15 years and over who are infected with HIV. Among young people ages (Table 4) in the Bahamas, Belize, Dominican Republic and Haiti, women s rate of HIV infection is at least double that of the rates among men. 9 A 2010 UNAIDS report on the status of HIV in the Caribbean indicated that the percentage of PLHIV who were female rose from 35% to 50% from 1990 to But there is wide variation by country in the estimates of females living with HIV, ranging from 26% in the Bahamas to 59% in Belize, Guyana and Trinidad and Tobago. 10 Nonetheless, PANCAP reported that the Epidemiology Unit of the Ministry of Health in Belize recommends that in an economic constrained setting and with limited resources, the priority must thus now be concentrated on men in both testing and engaging them 9 See Table 3: HIV Prevalence 10 UNAIDS. The Status of HIVin the Caribbean page 6. 12

14 earlier in the HIV infection. The report highlighted that There were 249 new HIV infections in That is approximately 10% higher than the 226 in of the newly infected individuals are females and 148 are males. 11 Despite that women made up 40% of new infections, the Ministry continues to recommend a policy focus on men. This reflects a very contradictory understanding of how gender should be integrated into public policy. Understanding the gender dimensions of HIV in the Caribbean requires an appreciation that the vulnerabilities faced by women and men are different and must be treated as such when designing policies and programs. To think of HIV prevention in terms of one group in isolation of the other is to lose sight of the goal of getting to zero. For young women especially, such a zero-sum understanding of gender relations is particularly dangerous because young women in the region typically have higher rates of HIV infection than their male counterparts. For example, in the Dominican Republic and Haiti, young women are up to 2 to 3 times more likely to be affected by HIV than young males in the same age group. 12 Table 3: HIV Prevalence Country Antigua & Barbuda Annual incidence of reported AIDS cases (per 100,000 population) last available yr Prevalence of HIV in the population years old 2009 Female Male Female Male Ratio of a female/male ND ND ND Aruba ND ND ND Bahamas Barbados Belize Cuba Dominica ND ND ND Dominican Republic ND ND French Guiana ND ND ND ND ND Grenada ND ND ND Guyana Haiti ND ND Jamaica Montserrat ND ND ND 11 Williams, Shane D. "HIV Hits Male Population Hard." The Guardian UNAIDS. The Status of HIV in the Caribbean Page 5. 13

15 St. Kitts Nevis ND ND ND St. Lucia ND ND ND St. Vincent ND ND ND Suriname ND ND Trinidad & Tobago ND= Data not available Source: Gender, Health and Development: Basic Indicators 2011 published by PAHO, UNFPA, UN WOMEN, UNECLAC Maternal Health and Family Planning While many Caribbean countries have made significant improvements in maternal health, the maternal mortality ratio of some countries remains worrisome. The World Health Organisation s (WHO) recent report on maternal mortality noted that the MMR of Latin America (in which Guyana was included) was 80 while that for the Caribbean alone was 190. Haiti s maternal mortality rate is considered high by the WHO standard and Haiti is one of a handful of countries outside of sub-saharan Africa with MMR of 350 or more, though the WHO report also acknowledged this is a. Guyana was also deemed to have made no progress in the area of reduction of maternal mortality by the WHO. It is among the Caribbean countries with the highest MMR 13 and along with Jamaica and Suriname, has seen an increase in maternal mortality over the past 20 years. 14 Lifestyle changes could be a contributing factor for increases in MMR in some countries, a recent WHO study has found that more than 1 in 4 maternal deaths are caused by pre-existing medical conditions such as diabetes, HIV, malaria and obesity, whose health impacts can all be aggravated by pregnancy. 15 Table 4: Maternal Mortality at a Glance (most recent data) Country/Region Ratio Rate considered high by WHO 350 Haiti 350 Latin America and the Caribbean 80 Caribbean* 190 Trinidad & Tobago 46 Guyana 280 Belize 53 *Bahamas, Barbados, Cuba, Dominican Republic, Grenada, Haiti, Jamaica, Puerto Rico, Saint Lucia, Saint Vincent and the Grenadines, Trinidad and Tobago. 13 See o 14 See Table 5: Trends in estimates of maternal mortality ratio (MMR, maternal deaths per live births) by 5-year intervals, , by country

16 Source: Trends in Maternal Mortality: 1990 to 2010 WHO, UNICEF, UNFPA and The World Bank estimates Table 5: Trends in estimates of maternal mortality ratio (MMR, maternal deaths per live births) by 5 -year intervals, , by country Country MMR Average annual % change in MMR between 1990 and 2015 Lifetime risk of maternal death 1 in: Proportion of maternal deaths among deaths of women of reproductive age % Progress towards MDG 5A Bahamas NA Barbados NA Belize NA Cuba NA Dominican Republic Making progress Grenada NA Haiti No progress Jamaica NA Puerto Rico NA Saint Lucia NA Saint Vincent and the Grenadines NA Suriname No progress Trinidad and Tobago NA Countries in red are countries where MMR has increased over 25 years. Source: Trends in Maternal Mortality: 1990 to 2015 WHO, UNICEF, UNFPA and The World Bank estimates. An overview of the region suggests a significant unmet need for contraception. The use of modern methods of contraception ranges from a low prevalence of 31% in Belize to a high of 70% in the Dominican Republic. Table 8 shows 47% of women ages 15 to 49 use female sterilization, the highest rate of such use in the region. 16 In Belize, the low rate of contraceptive use is understood to be the result of complex and intersecting factors. 16 See Table 6: Access to Contraceptive Services % Women aged 15 to 49 using contraceptive methods, (last available year) 15

17 Women stated that planned pregnancies were desirable, but often unachievable because of religious beliefs, cultural norms, the opposition of family members, lack of knowledge of contraceptive methods and male partners seeking control over women. Community leaders reported that men are often unsupportive of contraceptive use and that religious groups often seek to discourage contraceptive use. Both women and community leaders stated that in San Ignacio, women are expected to have families and that local religious groups discourage the use of contraception. 17 MMRs in the Caribbean must be understood in the wider socio-economic context and the health care systems of Caribbean countries. Both Haiti and Guyana are two economically vulnerable Caribbean countries with inadequate health care systems. While Guyana may have the most permissive laws on abortion in the English-speaking Caribbean it is inaccessible since the main public hospital does not provide the service. Back street abortions persist and claimed the life of at least one young woman in Table 6: Access to Contraceptive Services % W omen aged 15 to 49 using contraceptive methods, (last available year) Country Any Method Modern Methods Pill IUD Female Sterilization Male Sterilization Injection Male condom Antigua & Barbuda Aruba Bahamas Barbados Data not available Data not available Data not available Data not available Belize <1 5 4 Cuba < Dominica Dominican Republic French Guiana Grenada Data not available <1 4 2 Data not available Data not available Guyana < Haiti Data not available or applicable 2 Data not available or applicable 11 5 Jamaica Data not available or applicable Montserrat Data not available 17 Davidson, Charis R., Deborah L. Billings, and Daniela B. Friedman. "Understanding Family Planning in San Ignacio, Belize." Journal of Global Health, Spring (2013). 16

18 St. Kitts Nevis St. Lucia Data not available Data not available St. Vincent Data not available Suriname <1 3 4 Trinidad and Tobago < SRHR Advocacy in the Region Caribbean feminists have been at the forefront of global feminist advocacy for the full realisation of women s sexual and reproductive health and rights: The Convenors of both NGO forums were Barbadian women Nita Barrow convened the forum in Nairobi, while Billie Miller convened the Forum in Cairo following in the footsteps of Gloria Scott and Lucille Mair of Jamaica, who were among those who took leadership in the activities around International Women s Year (1975) and the ensuing UN Decade for Women. 18 Indeed, Barbadian women had access to safe and legal abortion in 1983, more than a decade before the International Conference on Population and Development (ICPD) would signal a global shift from population control to reproductive rights and health. This was due largely to the efforts of its sole woman Minister at the time, Dame Billie Miller. Her reflection on her strategy bears lessons for Caribbean activists currently working to advance SRHR in the region: I decided to put the issue [decriminalization of abortion] in the wider context of public health because it was broader than an exclusively women s issue. It was going to be a part of a suite of social legislation designed to uplift the rights of women and children. 19 In Guyana, activists used the momentum generated by the ICPD to secure legal abortion on demand in Speaking of the Guyana context today Fred Nunes has argued: 18 AHMED, AZIZA, CAROLE NARCISE, MAGGIE SHMEITZ, and MARSHA MASSAYA. Maternal Mortality, Abortion, and Health Sector Reform in Four Caribbean Countries: Barbados, Jamaica, Suriname, and Trinidad and Tobago. DAWN Caribbean and ASPIRE, 2005, page Miller, Dame Billie, and Nicole Parris. "Capturing the Moment: The Barbados Experience of Abortion Law Reform an Interview with Dame Billie Miller." Social and Economic Studies 61, no. 3 (2012): page Nunes, Fred. "Legal but Inaccessible: Abortion in Guyana." Social and Economic Studies 61, no. 3 (2012): page 63 17

19 There is no real culture of holding the Government accountable in Guyana. Since the 1970s, Guyana has been exporting its middle class. Both professional and civilian organizations are weak. 21 Nonetheless, Guyana has one of the most active women s movements in the region. Red Thread, a multiracial feminist organisation in Guyana has been a key critical voice on a range of gender and social justice issues. Patrice Daniel, has noted that: The Barbados Family Planning Association s (BFPA) Youth Advocacy Movement (YAM) was an example of good practice around youth/adolescent SRHR education in its heyday. YAM Barbados is, unfortunately, no longer active though there are hopes of reviving it in the relatively near future. The BFPA is affiliated with the International Planned Parenthood Federation (IPPF) which Patrice also views as supportive of her local advocacy work through technical support, training, capacity building, printed resources, a channel for awareness raising via posts on their blog and other social media platforms. The value of IPPF affiliated organisations as a resource and ally in SRHR advocacy in the region is uneven. Guyana s local IPPF affiliate, barely participated in the campaign for the new law and had done nothing to provide [abortion] services since the law. 22 Snapshot: SRHR in Caribbean Media Today, after two days of trial, Patrick Lorent, 32, was acquitted of three counts of carnal knowledge after the child s father could not remember her age, an important fact which had to be proven for the charge to stand. 23 Guyana s dismal record on maternal mortality would have contributed to the near-fail the region received on this target when the 2013 Millennium Development Goals (MDGs) report was released on Monday in Geneva, Switzerland. 24 Lack of justice for child sexual abuse survivors Maternal mortality 21 Ibid, Nunes, Fred. "Legal but Inaccessible: Abortion in Guyana." Social and Economic Studies 61, no. 3 (2012): page

20 Another litigant, Joseph Fraser, known as Peaches, said, There are plenty of trans genders out there who are looking for jobs; who don t feel comfortable in male clothes, so they are discriminated against because of the way they dress and as a result, engage in sex work to make an honest living. If the Chief Justice does not rule that this law is unconstitutional, everything will go back to square one and we will continue to be oppressed, Fraser added. 25 It doesn t matter what promise they make that if we don t decriminalize it [buggery] that they will stop whatever aid, he pointed out. We don t want that kind of aid because we will get AIDS Women also played deadly sexual politics... vaginal politics in the bedroom as a way to control their men, Bradshaw said. Asked to explain what he meant Bradshaw said that was using sex as a weapon of power and control big time in the bedroom. 26 Criminalization of trans women & Trans women s activism Homophobia and ignorance about HIV/AIDS Misogyny Recommendations SRHR advocacy in the Caribbean must be mindful of how misguided and narrow understandings of gender equality may result in adverse outcomes. Messaging must focus on the particular vulnerabilities faced by specific groups such as men who have sex with men, sex workers and young women, how such vulnerabilities are exacerbated by gender inequality and homophobia and must insist that policy and programming can and must focus on both women and men regardless of scarce economic resources

21 III. THEME 2: Sexual and Reproductive Health Rights of Young People Barriers to Comprehensive Sexuality Education Standardized Regional Health and Family Life Education (HFLE) Curriculum Frameworks exist which focus on 4 key themes: 1) Sexuality and HIV/AIDS Prevention, 2) Interpersonal Relationships and Violence Prevention, 3) Nutrition and Fitness, and 4) Managing the Environment UNICEF reported some difficulties from the teachers perspectives: limited time allocation for the curriculum; teacher preparedness and personal comfort with the subject matter; and, difficulties with completing the full HFLE curriculum. 27 It is reported that countries such as Antigua and Barbuda have implemented Christian Family Life Education (CFLE). Jamaica s current Minister of Education has recently announced a new HFLE curriculum that would exclude homosexuality and condoms. In Belize, the education system is a church-state partnership that has hindered the provision of adequate SRH education and services to the young and even to the rest of the public. In the Caribbean, primary and secondary school education on sex and sexuality continues to be inadequate, largely due to dominant religious moralities, and the idea that with increased information about sex and sexuality, children and adolescents will be encouraged to participate in sexual activities at an early age. This latter argument is also made in regards to lack of provision of condoms in schools. Child Sexual Abuse Human rights advocates have made strides with the inclusion of information on sex and sexuality in the HFLE curriculums in most public schools across the region; however, teachers report that some parents oppose their teaching of the full curriculum. Further some teach components in alignment with their personal belief systems. This is despite that many teachers are aware some of their students are sexually active, whether with adults or their peers. Furthermore, many teachers are aware of students who are being or have been sexually abused, and still fail to advocate for comprehensive sexuality education and protections for those students. Given the climate of child sexual abuse in the region, this is particularly troubling, as many young people develop risky sexual behaviours after being abused. Further, early sexual debut is common, and proper education and access to SRHR services remains inaccessible to persons engaging in sexual activities at a young age. 27 STRENGTHENING HEALTH AND FAMILY LIFE EDUCATION IN THE REGION The Implementation, Monitoring, and Evaluation of HFLE in Four CARICOM Countries,

22 There have been some successes in Grenada for example, where the Legal Aid and Counselling Clinic has been able to engage in early childhood education for the prevention of child sexual abuse. Generally however, the issues remain largely taboo. Topics such as sexual orientation and alternative sexualities are rarely/not discussed. Young people are therefore increasingly placed at risk, and their right to access comprehensive sexuality education denied. In a study undertaken on child sexual abuse in the Eastern Caribbean in , it was noted that Transactional sexual abuse was reported as being widespread and while it primarily involves girls and older men; increasingly boys are being sexually exploited. Transactional sexual abuse was described as quite visible, i.e. an open secret and often happens with the full knowledge of parents, communities and officials. Such is the extent of the problem, that it was considered a firmly entrenched and established pattern of behaviour that did not need to be hidden since it was unlikely to attract penalty, and in some circumstances, would not even attract disapproval. Transactional sex was reported as being committed by men at all levels of society, including politicians and senior professionals. The report also notes the effects of child sexual abuse on the level of the individual as including: Emotional Problems: including aggression and difficulties with sexual boundaries Psychological problems: including depression, self-harm, low self esteem Behavioural problems: including poor school performance, challenging behaviour, risky sexual behaviour, substance misuse and violence Legal Barriers for Youth Access to SRHR and Services Most Caribbean countries have set the age of consent to sex at 16, however the average age of sexual debut is lower for large percentages of persons in many Caribbean states. In Barbados for example, according to the Ministry of Health s Global AIDS Response Progress Report 2012, a 2011 KABP 29 Youth Survey revealed that 19.1% of the respondents between years reported to having sexual intercourse before the age of 15 years 30. Amongst other issues around the age of consent to sex, some criminal codes specify the age of consent only for girls. In St. Vincent and the Grenadines for example, 28 Perceptions of, Attitudes to, and Opinions on Child Sexual Abuse in the Eastern Caribbean, The report of a study carried out across the Eastern Caribbean during the period October 2008 to June The study emerged out of the UNICEF/Governments of the Eastern Caribbean Programme of Cooperation and was a joint programming initiative (UNICEF/UNIFEM together with stakeholders from the region) aimed at reducing sexual violence against children. The study was partially funded by the Department for International Development (DfID) to support the inclusion of countries designated as British Overseas Territory. Retrieved online 5 August 2013 at: 29 Knowledge. Attitudes, Behaviors and Practices (KABP) 30 Global AIDS Response Progress Report for Barbados, Ministry of Health, March 2012 (For the reporting period January December 2011). Retrieved online on 10 July 2013 at: eport%5b1%5d.pdf 21

23 where according to the Criminal Code cap. 124, 15 is the age for a girl to give consent to sexual intercourse 31. There is no reference made to the age of consent for a boy. Furthermore, there is tension in many states throughout the region regarding the age of medical consent, or the age at which a person does not require a parent or guardian s consent for medical services or procedures. For most medical professionals, the age of medical consent where not explicitly stated, is often equated with the age of majority, which is 18 years in most Caribbean states, and 21 years in others. UNFPA notes in a Legal Gap Analysis of Adolescent Sexual and Reproductive Health and Rights in Barbados 2011 that The confusion and insufficiency of the legislation has contributed to young people being refused and deterred from even enquiring about sexual and reproductive health treatment and services with fear of the consequences, on the basis that the legal age at which children become adults is eighteen 32. The biggest challenge concerning the age of medical consent is the gap between the age of consent to sex and the age of medical consent in many states. Often the age of consent to sex is 16, and the age of medical consent understood to be several years later, whether legally ascribed or assumed as such. The Global School Health Survey (GSHS) for Barbados in 2011 shows that among students who ever had sexual intercourse, the percentage who had sexual intercourse for the first time before age 14 years was 68.1%, 74.3% for boys and 56.1% for girls 33. Implications of this include that adolescents are dependent upon adults to access sexual and reproductive health services, including condoms and HIV testing, and as such are deterred from seeking sexual and reproductive health services. While there has been advocacy across the region in support of establishing the age of medical consent as the same as the age of consent to sex, this has not been widely supported in the political arena. Furthermore, bearing in mind the extent of incest, statutory rape and various forms of sexual violence in the region, there is much to be concerned about when we consider that adults caring for children and adolescents either perpetrate violence against them directly, or indirectly by failing to protect them from known abuse. Following on this is the inadequacy of the justice system in addressing child sexual abuse. In a UNICEF, Action for Children and University of Huddersfield supported study across the Eastern Caribbean undertaken from October 2008 to June 2009, it was found that: Respondents across all socio-economic groups were consistent in their responses 31 Retrieved online at: &skip=0, on 12 July Legal Gap Analysis of Adolescent Sexual and Reproductive Health and Rights in Barbados, Prepared by Ruth Henry UNFPA Caribbean Sub-Regional Office for the Caribbean Barbados is%20asrh%20barbados.pdf 33 Retrieved online on 21 July 2013 at Note: The GSHS was developed by the World Health Organization (WHO) in collaboration with United Nations' UNICEF, UNESCO, and UNAIDS; and with technical assistance from CDC. GSHS is a school-based survey conducted primarily among students aged years. The surveys for the region can be accessed at: 22

24 t... [and] show a lack of confidence in the ability of the police to deal effectively with child sexual abuse, nevertheless most respondents (82.3%) believe that sexual abuse should always be reported to the authorities which suggests that people do consider law enforcement to be an essential aspect of an effective child protection system. 34 Mapping SRH Services & Activism in Belize 35 The Belize Family Life Association is the organization most dedicated to providing and advocating for the provision of SRH services and information. BFLA has offices around the country with a registered nurse that provides services at a minimal cost such as pap smears and contraceptives. They also provide education to the community through various activities such as visiting schools, participating in community fairs, and radio shows. They have made conscious efforts to target young people by establishing a youth arm of BFLA known as the Youth Advocacy Movement (YAM). The Productive Organization for Women in Action operates in Dangriga Town which is in the southern part of Belize has an ongoing Pink POWA programme that targets girls from age 10 who are taught about self-esteem, sexual and reproductive health, and cultural retrieval (to strengthen selfesteem) among other prevalent social issues they are exposed to. Strengthening trust and team-building is also an objective of the program which involves regular meetings on Sundays with the girls. POWA is also currently conducting a program with adolescent boys and girls with similar focus on building self-esteem as well improving knowledge of gender and sexuality. Plenty Belize is in the Toledo district of Belize and they provide support services for teenage mothers as well as referrals. Since BFLA does not have the financial support to operate countrywide anymore Plenty has helped with a project to target and address teenage pregnancy in the Toledo District. The Belize Red Cross had a program called Together We Can which was an excellent program for youths dealing with SRH issues. They had trained many young people as peer educators. A lot of excellent initiatives have occurred in this country but too many have died due to lack of funding, lack of commitment, lack of continuity, lack of support etc. It is so unfortunate when there is no lack of sexual molestation and exploitation of our youths. 34 Perceptions of, Attitudes to, and Opinions on Child Sexual Abuse in the Eastern Caribbean The report of a study carried out across the Eastern Caribbean during the period October 2008 to June p. 91. Retrieved online on 21 July 2013 at: 35 This section was submitted by Ifasina Efunyemi of POWA, Belize. 23

25 IV. THEME 3: Sexual and Reproductive Rights Sex and Crime Legal systems and corresponding health services are limited in their provision of access to sexual and reproductive health and rights. This section of the tool interrogates the criminalisation of sexual activity, and highlights the impact of this on sexual health service provision. It will give an overview of the current status on abortion rights, and will explore challenges to the delivery of comprehensive sexuality education and services. Most legal frameworks dealing with sexual and reproductive health in the Caribbean serve to reinforce dominant religious, cultural and social norms, which equate sexual activity with heterosexuality and reproductive biological functions. Human rights and the fair and equal administration of justice seldom take precedence in courtrooms and around policy tables, as popular notions of sexual morality are reinforced at the expense of the individual right to safe, consensual sex, and all that it implies. Activists and others working to increase access to SRHR in the Caribbean must contend with the reality that the state determines to a large extent whether or not an individual is able to access their sexual and reproductive health rights. Policing Sexuality Same sex Relations Sexuality is policed by the state through the justice system well beyond what is the reasonable purview of the law. On the issue of same sex sexual relations in particular, many legal frameworks are overtly discriminatory and have criminalized to varying degrees corresponding sexual identities, expressions and practices (Table 7). The practice of anal sex, commonly referred to as buggery in many criminal codes, is the most commonly prohibited by law and is used as a way of prohibiting sex between males. Buggery is criminalized in Antigua and Barbuda, Barbados, St. Lucia, St. Vincent and the Grenadines, St. Kitts and Nevis, and Jamaica. Table 7: Criminalisation of same sex activity in the Caribbean Country Female same-sex activity criminalised Male same-sex activity criminalised Maximum punishment for buggery / abominable crime Bahamas No No N/A Antigua & No Yes 15 years Barbuda Trinidad & Yes Yes 25 years Tobago Barbados Yes Yes Life Guyana No Yes Life 24